Current levels of opioid-related morbidity and mortality in the United States are staggering. Data for 2017 indicate that there were more than 47,000 opioid-involved overdose deaths (roughly similar to deaths from AIDS at its peak in 1995; Centers for Disease Control and Prevention, 2011, 2018a), and the actual figure is likely 20 to 35 percent higher because death certificates do not always list specific drugs (Ruhm, 2018). Furthermore, these fatalities exclude those who die from complications from infectious diseases, such as HIV or hepatitis C, contracted by sharing injection equipment and do not account for the costs associated with opioid use disorder (OUD) and nonfatal overdoses. In contrast to every other developed country, overall life expectancy is dropping in the United States, with opioids being an important driver (Dowell et al., 2017; Centers for Disease Control and Prevention, 2018b). Moreover, one in eight adults now reports having had a family member or close friend die from a prescription painkiller or heroin overdose (Associated Press–NORC Center for Public Affairs, 2018). Since 2014, the increase in opioid-related deaths is primarily associated with illicitly produced synthetic opioids (e.g., fentanyl) being mixed into heroin and counterfeit pills (Centers for Disease Control and Prevention, 2017a). Because fentanyl and other synthetic opioids are much cheaper per morphine-equivalent dose and increasingly accessible from foreign suppliers, that pattern could well spread. The potential diffusion of these substances into nonopioid drug markets, such as for methamphetamine and cocaine, is also alarming.

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